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Showing papers by "Kim A. Eagle published in 2004"



Journal ArticleDOI
09 Jun 2004-JAMA
TL;DR: The GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS and Clinicians may find it simple to use and applicable to clinical practice.
Abstract: ContextAccurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy.ObjectiveTo develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS.Design, Setting, and PatientsA multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge. From 17 142 patients presenting with an ACS from April 1, 1999, to March 31, 2002, and discharged alive, 15 007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients admitted from April 1, 2002, to December 31, 2003.Main Outcome MeasureAll-cause mortality during 6 months postdischarge after admission for an ACS.ResultsThe 6-month mortality rates were similar in the development (n = 717; 4.8%) and validation cohorts (n = 331; 4.7%). The risk-prediction tool for all forms of ACS identified 9 variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram, and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively.ConclusionsThe GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS. Clinicians may find it simple to use and applicable to clinical practice.

1,457 citations


Journal ArticleDOI
01 Aug 2004-Chest
TL;DR: Patients with ACSs who present without chest pain are frequently misdiagnosed and undertreated, and each dominant presenting symptom independently identifies a population that is at increased risk of dying.

485 citations


Journal ArticleDOI
TL;DR: Insight is provided into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.
Abstract: Background— Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD). Methods and Results— Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustme...

417 citations


Journal Article
TL;DR: The GRACE 6-month post-discharge prediction model is a simple, robust tool for predicting mortality in patients with acute coronary syndrome (ACS) from the Global Registry of Acute Coronary Events (GRACE) as discussed by the authors.
Abstract: CONTEXT Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy. OBJECTIVE To develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS. DESIGN, SETTING, AND PATIENTS A multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge. From 17,142 patients presenting with an ACS from April 1, 1999, to March 31, 2002, and discharged alive, 15,007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients admitted from April 1, 2002, to December 31, 2003. MAIN OUTCOME MEASURE All-cause mortality during 6 months postdischarge after admission for an ACS. RESULTS The 6-month mortality rates were similar in the development (n = 717; 4.8%) and validation cohorts (n = 331; 4.7%). The risk-prediction tool for all forms of ACS identified 9 variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram, and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively. CONCLUSIONS The GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS. Clinicians may find it simple to use and applicable to clinical practice.

410 citations


Journal ArticleDOI
TL;DR: Several individual pharmacological agents, such as antiplatelet drugs, β-blockers, ACE inhibitors, and lipid-lowering agents, have proven efficacy in reducing mortality in patients with cancer as discussed by the authors.
Abstract: Background— Several individual pharmacological agents, such as antiplatelet drugs, β-blockers, ACE inhibitors, and lipid-lowering agents, have proven efficacy in reducing mortality in patients with...

330 citations


Journal ArticleDOI
TL;DR: Among patients prescribed key evidence-based medications at discharge, 8% to 20% were no longer taking their medication after 6 months, and the reasons for noncompliance are complex, and may be elucidated by future studies of medical and social determinants.

204 citations


Journal ArticleDOI
TL;DR: Heart failure hospitalizations have continued to increase from 1990 to 1999, and aging and growth of the US population contribute to this trend, the increases are substantially influenced by changes in hospitalization rates in women.

179 citations


Journal ArticleDOI
01 Oct 2004
TL;DR: Compared with patients who have painful AAD, patientsWho have painless AAD have higher mortality, especially when AAD is type B, and the prevalence of aortic rupture was higher among patients with type B dissection in group 1.
Abstract: OBJECTIVE To evaluate the clinical characteristics and outcomes of patients with painless acute aortic dissection (AAD). PATIENTS AND METHODS For this study conducted from 1997 to 2001, we searched the International Registry of Acute Aortic Dissection to identify patients with painless AAD (group 1). Their clinical features and in-hospital events were compared with patients who had painful AAD (group 2). RESULTS Of the 977 patients in the database, 63 (6.4%) had painless AAD, and 914 (93.6%) had painful AAD. Patients in group 1 were older than those in group 2 (mean ± SD age, 66.6±13.3 vs 61.9±14.1 years; P =.01). Type A dissection (involving the ascending aorta or the arch) was more frequent in group 1 (74.6% vs 60.9%; P =.03). Syncope (33.9% vs 11.7%; P P P =.03) were more frequent presenting signs in group 1. Diabetes (10.2% vs 4.0%; P =.04), aortic aneurysm (29.5% vs 13.1%; P P P =.05), especially due to type B dissection (limited to the descending aorta) (43.8% vs 10.4%; P P =.04). CONCLUSION Patients with painless AAD had syncope, congestive heart failure, or stroke. Compared with patients who have painful AAD, patients who have painless AAD have higher mortality, especially when AAD is type B.

169 citations


Journal ArticleDOI
TL;DR: Patients undergoing infrainguinal bypass are undertreated with respect to cardioprotective medications, and statin drug use is associated with improved graft patency and limb salvage.

144 citations


Journal ArticleDOI
TL;DR: The data indicate that a history of PCS (even that of previous AVR) should not preclude physicians from recommending surgical correction of type A aortic dissection in appropriate patients, including those undergoing surgical repair.
Abstract: Background— There are less data on the clinical and diagnostic imaging characteristics, management, and outcomes of patients with previous cardiac surgery (PCS) presenting with acute type A aortic dissection (AAD). Methods and Results— In 617 patients with AAD, we evaluated the differences in the clinical characteristics, management, and in-hospital outcomes of the cohorts with and without PCS. A history of PCS was present in 100 of 617 patients. Patients with PCS were more likely to be males ( P =0.02), older ( P =0.014), and to have a history of previous aortic dissection ( P P P P =0.007). Fewer AAD patients with PCS underwent surgical repair ( P =0.001). Hospital mortality was not adversely influenced by PCS (odds ratio [OR], 1.46; 95% confidence interval [CI], 0.81 to 2.63), but a trend for increased death was seen in patients with previous aortic valve replacement (AVR) (OR, 2.31; 95% CI, 0.98 to 5.43). Age70 years or older, previous AVR, shock, and renal failure identified PCS patients at risk for death. Conclusions— Our study highlights differences in clinical characteristics, management, and outcomes of AAD patients with PCS. Importantly, PCS, with the exception of previous AVR, does not adversely influence early outcomes of AAD patients, including those undergoing surgical repair. However, because of otherwise dismal outcomes with medical management of AAD, our data indicate that a history of PCS (even that of previous AVR) should not preclude physicians from recommending surgical correction of type A aortic dissection in appropriate patients.


Journal ArticleDOI
TL;DR: In men and women of all ages with the spectrum of ACS, initial leukocyte count is an independent predictor of hospital death and the development of heart failure.

Journal ArticleDOI
TL;DR: One of the most life-threatening cardiovascular emergencies, aortic aneurysm rupture or dissection, also demonstrates periodicity, characterized by a similar temporal distribution, which suggests a common pathophysiologic mechanism or triggers similar to other cardiovascular acute emergencies.

Journal ArticleDOI
TL;DR: It is suggested that, compared with TT, primary PCI is associated with a decrease in reinfarction and mortality, with no change in other outcome measures, in elderly patients with STEMI.

Journal ArticleDOI
TL;DR: The data support the importance of aneurysm surveillance and prophylactic surgical intervention for patients with Marfan's syndrome to potentially reduce the risk of mortality.
Abstract: Among 1,049 patients diagnosed with aortic dissection in a multinational registry, patients with Marfan's syndrome were typically younger and had unique presentations. Despite their younger age at presentation, patients with Marfan's syndrome and aortic dissection had a high mortality rate, similar to patients without Marfan's syndrome, an older patient cohort. Our data support the importance of aneurysm surveillance and prophylactic surgical intervention for patients with Marfan's syndrome to potentially reduce the risk of mortality.

Journal ArticleDOI
TL;DR: This study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes and proposes a simple decision rule that allows stepwise risk-stratification in elderly patients withABAD.

Journal ArticleDOI
TL;DR: It is indicated that dietetics professionals must continue to develop strategies to promote heart-healthy food choices in community restaurants as a trend toward a slight increase in heart- healthy menu item selections is shown.
Abstract: The research question examined in this study was: Does a promotional campaign impact the sales of heart-healthy menu items at community restaurants? The 8-week promotional campaign used professionally developed advertisements in daily and monthly print publications and posters and table tents in local restaurants. Nine restaurants tracked the sales of selected heart-healthy menu items and comparable menu items sold before and after a promotional campaign. The percentage of heart-healthy items sold after the campaign showed a trend toward a slight increase in heart-healthy menu item selections, although it was not statistically significant. This study and others indicate that dietetics professionals must continue to develop strategies to promote heart-healthy food choices in community restaurants.

Journal ArticleDOI
TL;DR: Patients who had acute coronary syndrome and received statins <24 hours of presentation had lower incidences of death, stroke, reinfarction, heart failure, and pulmonary edema compared with delayed administration.
Abstract: The clinical benefits of statins in acute coronary syndromes are well established, but the optimal time for administration in this setting has not been well studied. In this study, patients who had acute coronary syndrome and received statins <24 hours of presentation had lower incidences of death, stroke, reinfarction, heart failure, and pulmonary edema compared with delayed administration. Prompt administration of statins appears to be significantly beneficial in patients who present with an acute coronary syndrome.

Journal ArticleDOI
TL;DR: Evaluating work‐related outcomes of patients at 7 months after a myocardial infarction and identifying patient, disease, and intervention characteristics associated with these outcomes are identified.
Abstract: Study Objective. To evaluate work-related outcomes of patients at 7 months after a myocardial infarction and to identify patient, disease, and intervention characteristics associated with these outcomes. Design. Cross-sectional survey analysis. Setting. Large Midwestern academic health system. Patients. Eighty-nine patients with the discharge diagnosis of acute myocardial infarction during a 1-year index period. Intervention. Work performance questionnaire administered by telephone, and medical record review. Measurements and Main Results. Seven months after discharge, 232 patients were interviewed by telephone to determine work status before and after myocardial infarction, work-related outcomes (absenteeism and perceived work performance, assessed by the Work Performance Scale [WPS] of the Functional Status Questionnaire), and health-related quality of life. Univariate analyses were used to determine the association between individual characteristics and work-related outcomes. Of the 89 patients who had worked before the index myocardial infarction, 21 (23.6%) did not return to work. Variables associated with the outcome of not returning to work were past myocardial infarction (before the index myocardial infarction), coronary artery bypass graft surgery, heart failure, positive stress test, and low score on the Physical Component Summary (PCS-12) scale of the Short Form-12. Patients who did not return to work also tended to have more comorbidities and take more prescribed drugs than those who returned to work. Median WPS scores were higher for patients who had higher ejection fractions at discharge, had not experienced a myocardial infarction before the index event, underwent a percutaneous revascularization intervention at the time of hospitalization, and had not recently been absent from work. Workers reporting absences had lower PCS-12 scores than their counterparts or reported a rehospitalization before the survey. Conclusion. Preexisting cardiac disease and poorer physical functioning were consistently related to worse work-related outcomes. This small study demonstrates the need for a larger, broader study that includes health beliefs, treatment, and other job and patient factors that may influence work-related outcomes.

Journal ArticleDOI
TL;DR: The evaluation of cardiac risk before noncardiac surgical procedures and interventions aimed toward reducing that risk have become an integral part of the contemporary practice of medicine.
Abstract: The evaluation of cardiac risk before noncardiac surgical procedures and interventions aimed toward reducing that risk have become an integral part of the contemporary practice of medicine. In the ...

Journal ArticleDOI
TL;DR: “Appropriate” cardiovascular (CV) care used to be solely in the head of the beholder, but now it is in the hands of the clinician based on evidence.

Journal ArticleDOI
01 Sep 2004-Heart
TL;DR: Patients with and without diabetes are analysed with the goal of systematically examining similarities and differences in presentation, management, and outcomes when admitted for acute coronary syndromes (ACS).
Abstract: Several prior studies have shown that patients with diabetes mellitus have worse in-hospital outcomes compared to non-diabetic patients when admitted for an acute myocardial infarction (MI).1,2 Few studies have examined this same issue among patients admitted across the entire spectrum of acute coronary syndromes (ACS) (unstable angina, non-ST elevation MI, ST elevation MI).3,4 Since patients admitted with these diagnoses make up a large proportion of admissions to cardiology services and diabetic patients represent a sizeable portion of these patients, investigation of this cohort is clinically pertinent. In the present study, we analysed patients with and without diabetes, with the goal of systematically examining similarities and differences in presentation, management, and outcomes when admitted for ACS. We studied 1951 consecutive patients who were admitted to the University of Michigan Medical Center from 27 December 1998 to 16 October 2002 with a diagnosis of ACS. The protocol was approved by the institutional review board at the University of Michigan and informed consent was obtained from all patients. Diabetes was defined as a known history of type I or type II diabetes mellitus treated with diet, oral glucose lowering agents, or insulin. Patients utilising insulin for the management of their diabetes before admission were included in the insulin treated diabetic …

Journal ArticleDOI
TL;DR: Aortic dissection patients with renal insufficiency are at increased risk for drug-resistant hypertension and aortic branch vessel compromise and routine measurement of serum creatinine provides a readily accessible clinical marker for important complications.
Abstract: Morbidity and mortality from aortic dissection remain high despite advances in diag- nosis and treatment. Simple markers to identify patients at high risk for non-aortic complica- tions of dissection are lacking. We investigated the effect of renal insufficiency on the presentation, complications, and outcome of patients with acute aortic dissection. We evaluated 638 patients with type A and 365 patients with type B aortic dissection enrolled in the Interna- tional Registry of Acute Aortic Dissection (IRAD) between January 1996 and December 2000. Chi-squared and Student's t testing were performed to identify the effect of renal insufficiency on patient presentation, management, and outcome. Patients with renal insufficiency more often required nitroprusside for blood pressure control (type A: 40.7% vs 31.1%, p ¼ 0.049; type B: 66.7% vs 37.3, p ¼ 0.0001) and had a greater risk of mesenteric ischemia (type A: 10.7% vs 1.4%, p < 0.0001; type B: 17.7% vs 3.0%, p < 0.0001). In conclusion, aortic dissection patients with renal insufficiency are at increased risk for drug-resistant hypertension and aortic branch vessel compromise. Routine measurement of serum creatinine provides a readily accessible clinical marker for important complications. Upon recognition, renal impairment indicates a need for close monitoring, aggressive blood pressure control, and evaluation of aortic branch vessel circulations.


Journal ArticleDOI
TL;DR: This work critically review the literature regarding the prognostic implications of elevated biomarkers after coronary revascularization and make treatment recommendations on the basis of contemporary evidence.

Journal Article
TL;DR: Some patients with valvular heart disease and all patients with a mechanical valve prosthesis require long-term anticoagulation, which must be managed during the perioperative period, which reduces the risk of infective endocarditis.
Abstract: Valvular heart disease in a variety of forms is not uncommon, especially among older patients undergoing noncardiac surgery, and can be associated with increased perioperative cardiac risk. Patients with aortic stenosis are at greatest risk, although other valve lesions also can pose the risk of increased perioperative morbidity. During preoperative evaluation, attention to the presence, nature and severity of valvular heart disease allows appropriate perioperative monitoring and therapy with a goal to minimize the risk of perioperative cardiac morbidity and mortality associated with noncardiac surgery. Appropriate antibiotic prophylaxis reduces the risk of infective endocarditis. Finally, some patients with valvular heart disease and all patients with a mechanical valve prosthesis require long-term anticoagulation, which must be managed during the perioperative period.


Journal ArticleDOI
TL;DR: There was no correlation between peak TnI levels and renal function as measured by Cr-Cl in the entire cohort with ACS and in the subgroups with ST elevation myocardial infarction and non ST elevationMyocardial Infarction.
Abstract: Background: Whether renal insufficiency (RI) influences troponin levels in patients with acute coronary syndromes (ACS) is controversial. We attempted to determine whether there is

Journal Article
TL;DR: Aggressive risk factor and lifestyle modification and pharmacologic therapies improve patient survival, reduce recurrent events, and improve quality of life in post‐myocardial infarction patients.
Abstract: • Objective: To review secondary prevention strategies for patients with acute coronary syndrome. • Methods: Review of the literature. • Results: Patients with acute myocardial infarction represent an important high-risk cohort in which secondary vascular disease prevention is likely to be particulary effective and cost-effective. Lifestyle modification such as regular exercise, weight management, and smoking cessation should be encouraged. Tight glucose control in diabetics and optimal blood pressure control are important goals. Effective pharmacologic therapies include statins, antiplatelet agents, β blockers, and angiotensin-converting enzyme inhibitors. Attention to disease management opportunities may improve quality of care for acute myocardial infarction patients. • Conclusion: Aggressive risk factor and lifestyle modification and pharmacologic therapies improve patient survival, reduce recurrent events, and improve quality of life in post‐myocardial infarction patients.